Hi Christopher, I agree with your assessment that we need to standardize the structure. Free text has the ease for the clinican with certain pain paucity of time. I am talking in the Developing country context. Further clinican are at time hesitant to record history in a pressured environment at service points as the Outpatients. A survey was done in India of what the clinicians want the surprising finding was hat they want a easy and quick way to capture all the relevant data and have the free text field to capture data not captured in a structured manner. Further I shall request the comments of all on the last mail wherein I clarified what I had in mind when I started this line.
Dr B S Grewal PGIMER(Post Graduate Institute Of Medical Education and Research) bobdog at sancharnet.in ----- Original Message ----- From: "Christopher Feahr" <ch...@optiserv.com> To: "Gerard Freriks" <gfrer at luna.nl>; "Thomas Clark" <lakewood at copper.net> Cc: "Karsten Hilbert" <Karsten.Hilbert at gmx.net>; <openehr-technical at openehr.org> Sent: Monday, August 11, 2003 8:09 PM Subject: Re: HISTORY DATA SET IN EPR > Hello Gerard, > You make excellent points. My intent is only to move toward a global > standard structure for health information that lends itself to such an > approach. Standardizing the structure of 80% of the content in medical > records would be a vast improvement over the present. > > In a very real sense, even free-text, narrative information is > "structured and coded" in the form of ASCII symbols... still an > improvement over hand-written paper charts. If the medical concepts, > however, are so complex for a particular encounter that we must utilize > a coding structure as complex as "English" to express them.. then that's > what we'll have to use. English is certainly a more difficult structure > for computers to work with, but not impossible. > > Christopher J. Feahr, O.D. > Optiserv Consulting (Vision Industry) > Office: (707) 579-4984 > Cell: (707) 529-2268 > http://Optiserv.com > http://VisionDataStandard.org > ----- Original Message ----- > From: "Gerard Freriks" <gfrer at luna.nl> > To: "Christopher Feahr" <chris at optiserv.com>; "Thomas Clark" > <lakewood at copper.net> > Cc: "Karsten Hilbert" <Karsten.Hilbert at gmx.net>; > <openehr-technical at openehr.org> > Sent: Monday, August 11, 2003 3:35 PM > Subject: Re: HISTORY DATA SET IN EPR > > > > Hi, > > > > As a GP with 20 years of experience in the Netherlands I learned that > free > > text plus a not to complicated set of codes (ICPC) is sufficient for > daily > > practice. We could generate automatic advice for medication based on > > complaints or diagnosis. > > > > ICPC contains roughly 2000 complaints, diagnoses and procedures. > > It will cover 80% of every thing a GP will encounter during the day. > > > > The provision of medicine is an art. > > The registration of all medical (and other) relevant facts and > findings is > > retelling the story of the pati?nt. It is a narritive process. > > Have we ever seen a piece of literature completely written in complex > codes? > > > > The study of Archetypes (see the OpenEHR website) will reveal that > > Archetypes plus free text plus codes will enable future physicians a > lot of > > flexibility and expressive power. > > Much of the flexibility will depend on the ontology (medical knowledge > and > > knwoledge of the world) behind the scenes. > > > > And bye the way. > > In the R&D facility where I work we have a very powerfull tool for > analysis > > of free text. Recently a lot of progress has been been at this. > > If the free text is 'enriched' with Archetypes this process of > meaningfull > > data extraction will become much more easy. > > > > Gerard Freriks > > > > -- > > Gerard Freriks, MD > > Convenor CEN/TC251 WG1 > > > > TNO-PG > > Zernikedreef 9 > > Leiden > > The Netherlands > > > > +31 71 5181388 > > +31 654 792800 > > > > > > > > > > -- <private> -- > > Gerard Freriks, arts > > Huigsloterdijk 378 > > 2158 LR Buitenkaag > > The Netherlands > > > > +31 252 544896 > > +31 654 792800 > > > > > > > From: "Christopher Feahr" <chris at optiserv.com> > > > Organization: Optiserv Consulting > > > Reply-To: "Christopher Feahr" <chris at optiserv.com> > > > Date: Mon, 11 Aug 2003 07:32:52 -0700 > > > To: "Thomas Clark" <lakewood at copper.net> > > > Cc: "Karsten Hilbert" <Karsten.Hilbert at gmx.net>, > > > <openehr-technical at openehr.org> > > > Subject: Re: HISTORY DATA SET IN EPR > > > > > > Presently, each doctor and EMR software vendor is cooking up his own > > > shorthand-language, and I'm suggesting that information should be > > > reduced as much as possible to a standard set of codes. > > > > - > > If you have any questions about using this list, > > please send a message to d.lloyd at openehr.org > > - > If you have any questions about using this list, > please send a message to d.lloyd at openehr.org > - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
